Explore chapters and articles related to this topic
Optic Neuropathies Associated With Multiple Sclerosis (MS) and Neuromyelitis Optica Spectrum Disorders (NMO-SD)
Published in Vivek Lal, A Clinical Approach to Neuro-Ophthalmic Disorders, 2023
CRION was introduced to describe a clinically defined syndrome, where the optic neuritis is recurrent and corticosteroid dependent as well as being corticosteroid responsive. That is to say when the acute treatment is withdrawn, the patient relapses. It is indeed remarkable that in MSON, it is possible to give 3 days of high dose corticosteroids and to discontinue this abruptly without fear of relapse. Although often a short tapering dose of oral treatment is given, it is not required to prevent early relapse. This certainly would not be recommended in NMO-SD, but a particular group of patients with a tendency to long-term corticosteroid dependence have been identified. Where the diagnosis is not certainly MSON, then a longer course of oral treatment is recommended with a gradual taper instructing the patient to report immediately if there is a return of symptoms. The clinically defined entity of CRION is most likely to be associated with anti-MOG antibodies or to be seronegative.
Vesiculobullous Diseases
Published in Ayşe Serap Karadağ, Lawrence Charles Parish, Jordan V. Wang, Roxburgh's Common Skin Diseases, 2022
Snejina Vassileva, Kossara Drenovska
Management: Systemic steroids, such as prednisone (0.5 to 1.5 mg/kg/day), are the treatment of choice in pemphigus. Once control of the disease is achieved, dose tapering is undertaken followed by long-term maintenance therapy. The use of steroid-sparing immunomodulatory agents, such as azathioprine (1–2.5 mg/kg/day), mycophenolate mofetil (2 g/day) or mycophenolic acid (1440 mg/day), or cyclophosphamide (50 mg/d p.o. or 500–750 mg/month i.v.), helps to diminish the steroid side effects. Dapsone (100–300 mg/day) may be useful in PH, while retinoids or synthetic antimalarials are to be considered in pemphigus vegetans or some cases of superficial pemphigus. In severe or corticosteroid-resistant disease, high doses of intravenous immunoglobulins (IVIG; 2 g/kg per cycle of 2–5 days) or rituximab (2 infusions of 1000 mg two weeks apart, with maintenance treatment of one infusion of 500 mg at month 12 and 18), may be taken into consideration. Recently, rituximab alone or in combination with systemic steroids was suggested as first-line treatment in pemphigus. Recalcitrant cases may also be treated by plasmapheresis, immunoadsorption, or extracorporeal photochemotherapy (photopheresis). Extensive mucocutaneous lesions require the topical application of antiseptic solutions, antibiotics, and corticosteroid creams, as well as treatment of any superimposed candidosis.
Medications
Published in Henry J. Woodford, Essential Geriatrics, 2022
After long-term use of sedative drugs, typical advice is to wean the dose down in steps over six to eight weeks. Once at low doses, if reducing to a dose that can't be easily divided, it can be switched to alternate-day dosing, then every third day. There is a risk of withdrawal effects, e.g. anxiety, insomnia, restlessness, inattention and muscle spasms. These are more likely with higher doses and longer duration of use. Withdrawal symptoms can take days to weeks to resolve. The risk is reduced by dose tapering. With the help of a variety of techniques, most older people can be weaned off sedative medications.43,44
Intermediate Uveitis: A Review
Published in Ocular Immunology and Inflammation, 2023
Andrea York Tiang Teo, Bjorn Kaijun Betzler, Keith Low Qie Hua, Elizabeth Jiahui Chen, Vishali Gupta, Rupesh Agrawal
Corticosteroids may also be given systemically. It was reported that patients treated with oral prednisolone showed a more rapid decrease in macular edema along with quicker improvement in visual acuity as compared to patients given a posterior sub-tenon injection of triamcinolone acetonide, indicating the utility of a short course of oral corticosteroids in patients with IU and macular edema.193 However, concerns over the systemic side effects with oral administration remain, thus it is recommended to use high dose oral corticosteroids only in severe disease or if local administration is ineffective, and for no longer than 1 month,194 after which the dose should be tapered. For chronic diseases, the target dose after tapering is ≤7.5 mg/day. To decrease the risk of relapse and withdrawal, tapering should be done with successively smaller decrements.194 Besides corticosteroids, local management of CME includes the use of topical non-steroidal anti-inflammatory drugs (NSAIDs), while systemic therapies may rely on immunomodulatory drugs or biologic agents as well.92
Primary care management of Long-Term opioid therapy
Published in Annals of Medicine, 2022
Phillip O. Coffin, Rebecca S. Martinez, Brian Wylie, Bunny Ryder
Before making a decision to taper opioids, it is important to get to know the patient and their stressors, as described above. Clinicians should have already asked the patient about their perceived risks and benefits of opioid therapy, and reviewed mental health and social barriers to a successful taper. Risks related to an opioid taper include worsening pain, use of non-prescribed opioids, overdose due to reduced tolerance, and even suicide. Risks should be discussed openly with the patient. Benefits of a successful taper should be discussed, including similar or improved pain and reduced burden of and stigma related to taking opioid medications [16]. Tapering should almost never result in withdrawal symptoms, however the aetiology of opioid withdrawal is complex. If the patient or clinician is concerned about withdrawal or the patient has a history of experiencing opioid withdrawal symptoms, medications can be provided (e.g. clonidine for sweats and feeling jittery, hydroxyzine for anxiety and insomnia, ondansetron for nausea and vomiting, loperamide for diarrhoea, and NSAIDs or acetaminophen for body aches).
Advances in pharmacotherapy for acute and recurrent pericarditis
Published in Expert Opinion on Pharmacotherapy, 2022
Alessandra Vecchié, Marco Giuseppe Del Buono, Adolfo Gabriele Mauro, Paul C. Cremer, Massimo Imazio, Allan L. Klein, Antonio Abbate, Francesco Dentali, Aldo Bonaventura
Rilonacept is administered as a subcutaneous injection with a loading dose of 320 mg delivered as two subcutaneous injections of 160 mg each given on the same day at two different sites in adults (4.4 mg/kg in those aged ≥12 and <18 years), followed by weekly doses of 160 mg (2.2 mg/kg in those aged ≥12 and <18 years) delivered as a single subcutaneous injection [60,61]. The half-life is 6.3 days in the pediatric population and 7 days in adults. There is no dose adjustment based on age, body weight, and liver or renal function, although no studies have evaluated the pharmacokinetics of rilonacept in these different conditions. Rilonacept is a pregnancy category class C (i.e. no controlled studies in humans despite animal studies have shown an adverse effect on the fetus, but potential benefits may warrant use of the drug in pregnant women despite potential risks) [61]. A progressive tapering is usually suggested after 6 months of controlled symptoms. However, data from the RHAPSODY trial suggested that tapering of rilonacept was not necessary due to the gradual washout pharmacokinetics of the drug over 5 to 8 weeks [62]. The long-term extension phase of the RHAPSODY with a planned treatment duration up to 2 years will be helpful to evaluate the resolution of autoinflammation [63]. In addition, the Registry of the Natural History of Recurrent Pericarditis in Pediatric and Adult Patients (RESONANCE; NCT04687358) trial will represent an opportunity to evaluate a large population of patients with recurrent pericarditis treated with real-world drugs.